Risk factors affecting graft survival rate in living-donor renal transplantation

의학과/석사[한글] 말기 신부전증의 치료로써 신장이식은 1954년 Murray에 의해 일란성 쌍생아간에 처음으로 성공을 거둔 이래 현재까지 꾸준한 이식성적의 향상이 있어, 1950, 1960년대에 시행된 혈연간 이식의 경우 이식신 2년 생존율이 57.2%에 불과했던 것이 1980년대에는 90% 이상으로 향상되었다. 이러한 신자이식 성적의 향상은 여러 가지 요소에 기인한다고 생각되어지는 바, 우선 이식전 준비단계로 복막투석과 혈액투석 및 이를 위한 vascular access의 발달, 수술기법의 개발, 수술전후 처치의 발달, 면역학적 개념의 발달과 수술전 수혈의 효과, 그리고 특히 새로운 면역억제제인 cyclosporine(CSA)의 개발이 그것이다. 외국에서는 사체신이식이 많이 행하여지고 있는 반면, 우리나라에서는 주로 생체신이식이 행해지고 있으나 이의 성적에 미치는 인자들에 대한 분석 결과가 다소간 부족한 점이 있어, 연세의료원에서 시행된 생체신이식의 결과를 토대로 우리나라에서 생체신이식의 생존율에 영향을 미치는 인자들에 대해 그 각각의 중요성을 분석하여, 추후 이식환자의 이식후 성적을 예견하는데 도움이 되고 이를 치료의 지침으로 활용하기 위해 본 연구를 하 였다. 연세대학교 의과대학 외과학교실에서는 1979년 4월 신장이식을 시작한 이래 1987년 7월까지 200예를 시행하였다. 이중 1981년 4월부터 시행한 150예의 1차 생체신이식을 대상으로 이식성적에 영향을 미치는 인자들에 대하여 분석한 결과 다음과 같은 결론을 얻을 수 있었다. 1) 생체신 이식성적에 영향을 미치는 인자는 신장이식 수여자의 연령, ABO 부적합성 여부, 사용한 면역억제제의 종류등의 3가지로 분석되었다. 2) 이식환자의 연령이 40세 이전의 경우 이식신 2년 생존율은 90.9%인데 비해 40세이후는 77.4%로 통계적으로 의의있는 차이가 있었다. azathioprine(AZA)처치군에서는 이식신 2년 생존율이 각각 86.2%, 65.2%인 반면 CSA처치군에서는 95.0%, 88.6%를 나타내어 CSA를 사용하는 경우 신장이식 수여자의 연령이 신장이식 성적에 미치는 영향은 미미하였다. 3) 공-수여자 관계가 이식성적에 미치는 영향 정도는 CSA 처치군에서 혈연간 이식신 2년 생존율이 95.0%, 비혈연간의 이식신 2년 생존율이 90.9%로 별 의미가 없는 것으로 분석되었다. 4) HLA항원 적합성 정도가 이식성적에 미치는 영향은 통계적 유의성은 없으나 class Ⅰ, Ⅱ항원 적합성 정도에 따라 AZA 처치군에서는 이식신 2년 생존율의 차이가 각각 13.3%, 14.1%였지만, CSA처치군에서의 차이는 각각 6.4%, 0.5%로 그 영향 정도가 CSA를 씀으로써 많이 감소하였다. 5) CSA처치군의 이식신 2년 생존율은 92.7%로 AZA처치군의 79.0%에 비해 13.7%의 향상을 보였다. 6) CSA처치군에서 공여자특이 수혈을 한 군과 하지 않은 군에서의 이식후 2년 생존율은 각각 94.7%, 90.9%로 모두 90%이상의 좋은 성적을 보여 이식전 수혈이 꼭 필요한 처치가 아닌 것으로 분석되었다. 7) 동일혈액형간의 이식신 2년 생존율이 91.1%로 다른 혈액형간의 77.5%보다 좋은 결과를 보였다. AZA를 면역억제제로 사용한 경우는 각각 87.9%, 53.8%로 ABO혈액형이 minor incompatible한 경우에는 이식성적이 현저히 떨어지는 양상을 보였다. 그러나 이러한 차이는 CSA를 사용함으로써 두 그룹에서 각각 94.1%, 90.4%의 성적을 나타내므로 ABO부적합성이 이식성적에 미치는 영향은 거의 없음을 알 수 있었다. 이상과 같은 결과로 비혈연간 이식이나, HLA항원이 부적합한 경우에도 면역억제제로 CSA를 사용하여 이식신 2년 생존율 90%이상의 양호한 이식성적을 기대할 수 있으며, CSA를 사용함으로써 이식전 수혈과 같은 수술전 처치의 필요성을 감소시켜 이로 인한 부작용이 나 합병증을 피할 수 있을 것으로 생각된다. [영문] As a treatment of ESRD, the first, successful renal transplant between identical twin was carried out by Dr. Murray in 1954. The outcome of renal transplant have improved ever since. The two-year graft survival rate for transplant between relatives was only 57.2% in 1950's and 60's. It has increased to more than 90% in 1980's. Many factors are thought to be contributing to such an improvement. They are improvement in transplant immunology with HLA-operative management, and development of new immuno-suppressive agent, cyclosportine(CSA). In Korea, the renal transplants from living donors are usually carried out, on the contrary to cadaver transplants done in other countries. But so far, few studies were done on living-donor transplants. Therefore, we made a study on the factors contributing to the graft survival rates of living-donor renal transplants carried out at Yonsei Medical Center. As a result of this study, we hope to predict better the post-transplant result, and to offer a more effective treatment for them. The Department of Surgery at Yonsei University, College of Medicine, first started the renal transplant program in April, 1979. There were 200 transplants from 1979 to July 1987. Among them, 150 primary transplantations done since April 1981 were studied, and then we made the following conclusions regarding the factors influencing the transplant outcome. 1) The result of living-donor transplant were influenced by recipient's age, ABO incompatibility, and immunosuppressive agents. 2) The recipients with age below forty showed 90.9% 2-year graft survival rate; above forty, 77.4%, showing statistical significance. For Azathioprine (AZA) - treated groups, pre- and post-forty results were 86.2% and 65.2%, respectively. For CSA-treated groups, they were 95.0% and 88.6%, with a considerable reduction in differences of graft survival rates for recipients with age above forty. 3) The CSA-treated group showed 2-year graft survival rate of 95% for related donors and 90.9% for unrelated donors. 4) There was no statistical significance for HLA antigen compatibility on transplant outcome. But for class Ⅰ and Ⅱ antigen matching, the AZA-treated group showed difference in 2-year graft survival rate of 13.3% and 14.1%, respectively. The CSA treated group showed difference of 6.4% and 0.5%. 5) The 2-year graft survival rates were 92.7% for CSA-treated group and 79.0% for AZA-treated groups. 6) For CSA-treated groups, the 2-year graft survival rate with donor-specific transfusion was 94.7%; without transfusion, 90.9%, both cases showing results above 90%. 7) The 2-year graft survival rate between identical blood groups was 91.1%, compared to 77.5% for non-identical groups. Moreover, for AZA-treated groups the rate for identical groups was 87.9%, and for ABO minor incompatibility, 53.8%. However, with CSA the rates were 94.1% and 90.4%. Thus ABO compatibility had no influence on transplant outcome for CSA-treated group. Thus, with CSA as an immunosuppressive agent the 2-year graft survival rate of over 90% can be expected even for transplants between unrelated and for HLA mismatching. With CSA, there was no need for pre-transplant immune modulation, such as pretransplant transfusion, and the side effects and complications from such procedures can be avoided.restrictio

육각형 격자 노심해석을 위한 해석적노달법 연구

학위논문(석사)--서울대학교 대학원 :원자핵공학과,1996.Maste

Emergency cricothyrotomy for trismus caused by instantaneous rigor in cardiac arrest patients

Instantaneous rigor as muscle stiffening occurring in the moment of death (or cardiac arrest) can be confused with rigor mortis. If trismus is caused by instantaneous rigor, orotracheal intubation is impossible and a surgical airway should be secured. Here, we report 2 patients who had emergency cricothyrotomy for trismus caused by instantaneous rigor. This case report aims to help physicians understand instantaneous rigor and to emphasize the importance of securing a surgical airway quickly on the occurrence of trismus

Characteristics of patients who visit the emergency department with self-inflicted injury

During visits to emergency medical facilities, the primary care of and risk identification for individuals who have attempted suicide is considered an important element in suicide prevention. With the ultimate goal of helping to prevent suicide, the aim of the present study was to determine the characteristics of patients with self-inflicted injuries who presented in the emergency department. Patients with self-inflicted injuries who visited 1 of 3 sentinel emergency medical centers from 2007 through 2009 were included in the study. The characteristics, methods, and reasons for suicide attempts were evaluated. Moreover, predictors of severe outcomes were evaluated. A total of 2,996 patients with self-inflicted injuries visited the three centers during a period of 3 yr. The male-to-female suicide ratio was 1:1.38 (P < 0.001). The mean age was 41 yr. Poisoning was the most common method of self-inflicted injury (68.7%) among all age groups. Medication was the primary means of injury in the < 50 age group, and the use of agricultural chemicals was the primary means in the ≥ 50 age group. The reasons for attempting suicide varied among the age groups. The predictors of severe outcome are male gender, older age, and not having consumed alcohol. © 2012 The Korean Academy of Medical Sciences

(A)Study on enhancement of computational efficiency for transient nodal calculations

학위논문(박사)--서울대학교 대학원 :원자핵공학과,2003.Docto

Epidemiology of childhood injury in Korea

Injury is the leading cause of mortality in children. The mortality from injury in children in Korea is higher than those in other developed countries in OECD. We analyzed the characteristics of mortality and hospital admission in childhood injury. The leading cause of mortality is traffic accident, followed by drowning and falls. The most common body site of injury leading to mortality is the head. The severity of most injuries is mild and the admission rate is about 15%. The most common causes of hospital admission are traffic accident and falls. Of traffic accidents, pedestrian injury is the most frequent in all children, but occupant injury is more common in children under age 4. The common place of injury is home, and most injuries are preventable for children under 4 years old

Validation of the International Classification of Diseases 10th Edition-based Injury Severity Score (ICISS)

Objective: To compare the predictive power of International Classification of Diseases 10th Edition (ICD-10) -based International Classification of Diseases 9th Edition-based Injury Severity Score (ICISS) with Trauma and Injury Severity Score (TRISS) and ICD-9CM-based ICISS in the injury severity measure. Methods: ICD-10 version of survival risk ratios was derived from 47,750 trauma patients from 35 emergency centers for 1 year. The predictive power of TRISS, the ICD-9CM-based ICISS and ICD- 10-based ICISS were compared in a group of 367 severely injured patients admitted to two university hospitals. The predictive power was compared by using the measures of discrimination (disparity, sensitivity, specificity, misclassification rates, and receiver operating characteristic curve analysis) and calibration (Hosmer-Lemeshow goodness-of-fit statistics), all calculated by logistic regression procedure. Results: ICD-10-based ICISS showed a lower performance than TRISS and ICD-9CM-based ICISS. When age and Revised Trauma Score were incorporated into the survival probability model, however, ICD-10-based ICISS full model showed a similar predictive power compared with TRISS and ICD-9CM-based ICISS full model. ICD-10-based ICISS had some disadvantages in predicting outcomes among patients with intracranial injuries. However, such weakness was largely compensated by incorporating age and Revised Trauma Score in the model. Conclusion: The ICISS methodology can be extended to ICD-10 horizon as a standard injury severity measure in the place of TRISS, especially when age and Revised Trauma Score were incorporated in the model. For patients with intracranial injuries, the predictive power of ICD-10-based ICISS was relatively low because of differences in the classifying system between ICD-10 and ICD- 9CM

Catabolic effect of morphine on protein metabolism

의학과/박사[한글] 몰핀이 1985년 포유동물의 조직에서 발견되고 생체내 합성이 증명되면서 내인성 몰핀도 내인성 아편계 펠타이드인 β-endorphin과 마찬가지로 외상이나 수술 후의 생체 항상성에 중요한 역할을 하는 것으로 여겨지고 있다. 생체 항상성에 있어 단백질 대사가 중요한 부분을 차지하고 있으나 현재까지 대사에 대한 몰핀의 영향은 주로 당대사에 집중되어 있을 뿐 단백질 대사에 미치는 영향은 거의 연구된 바가 없다. 본 연구에서는 몰핀 주입에 의한 아미노산의 대사변화와, 이에 관련된 각 홀몬의 변화를 알아봄으로써 몰핀에 의한 아미노산 대사 변화의 기전을 알아보고자 하였다. 실험동물로는 잡종개 11마리를 사용하여 한 군에서는 몰핀을 정맥내로 주입하고 다른 한 군에서는 뇌실내로 주입하여 각각 당과 leucine의 대사, insulin, cortisol, catecholamine 등의 홀몬을 측정하여 다음과 같은 결과를 얻었다. 1. 몰핀은 혈액에서 뇌척수액으로의 이동은 15% 정도 일어나나 뇌척수액에서 혈액으로의 이동은 없었다. 2. 몰핀 주입에 의한 당대사의 변화는 정맥내 주입시 보다 뇌실내 주입시에 더 급격한 변동을 보이며, 이때 간에서의 당 평형상태가 의의있게 증가하였다. 3. 몰핀의 뇌실내 주입시에 leucine 농도가 증가하며, 이때 간에서의 leucine 평형상태가 의의있게 증가하였다. 정맥내 주입시에는 leucine 농도는 감소하나 장관내 leucine 평형상태는 변동이 없었다. 4. 몰핀을 주입 후에 혈중 cortisol 및 catecholamine의 농도가 증가하며, 정맥내 주입시 보다 뇌실내 주입시 더 많이 증가하였다. 5. 몰핀의 정맥내 주입시에는 insulin 분비가 증가하는 반면, 뇌실내 주입시에는 혈당이 더 증가함에도 불구하고 insulin 분비는 억제되었다. 이상의 결과로 보아 몰핀은 교감신경계와 뇌하수체-부신축의 활성화로 인한 스트레스 홀몬의 증가와 더불어 insulin 분비 억제에 의해 단백질의 이화효과를 나타내며 이는 말초성이 아니라 중추성 효과에 의한 것으로 생각된다. Catabolic effect of morphine on protein metabolism Koo Young Jung Department of Medical Science, The Graduate School, Yonsei University (Directed by Professor Young Soo Ahn) In 1985, morphine was isolated from several mammalian tissues, and its endogenous synthetic pathway has been discovered to be the same in plants such as the poppy (Papaver somniferum). Endogenous morphine is supposed to have a certain role in homeostasis after trauma and severe illness as β-endorphin, an endogenous opioid peptide, does. Protein metabolism is one of the key components in the homeostasis. However, most studies about the effect of morphine on metabolism has been focused on the glucose metabolism. The purpose of this study is to investigate the mechanism of catabolic effect of morphine on the protein metabolism by analyzing protein metabolism and the levels of catabolic hormones after exogenous morphine administration. Morphine was infused intravenousely to one group of mongrel dogs, and intracerebroventricularly to another group. The glucose and leucine concentration and splanchnic balance were analyzed in each dog, and insulin, cortisol, and catecholamines were assayed. The following results were obtained. 1. About 15% of the infused morphine passed through the blood-brain-barrier from plasma to cerebrospinal fluid, but there was no appreciable movement from cerebrospinal fluid to plasma. 2. After intra cerebroventricular infusion of morphine, it was noticed that the increase of glucose concentration was more prominant than after intravenous infusion in the early phase. At the same time hepatic and splanchnic g1ucose balance was significantly increased in intracerebroventricular infusion group. 3. Intracerebroventricular infusion of morphine increased the concentration of plasma leucine with increasing the hepatic and splanchnic leucine balance. But intravenous infusion decreased the plasma leucine concentration without any significant chanties of hepatic and splanchnic leucine balance. 4. The increases of cortisol and catecholamines were more prominent after intracerebroventricular infusion than intravenous infusion. 5. While the plasma insulin concentration was increased after intravenous infusion of morphine, it was not increased after intracerebroventricular infusion despite of higher blood glucose concentration. These results suggest that morphine has catabolic effect on protein metabolism by suppressing the secretion of insulin as well as by increasing the stress hormones via activating the sympathetic nervous system and pituitary-adrenal axis. This effect is supposed to be mediated by contract opioid system, not peripheral. [영문] In 1985, morphine was isolated from several mammalian tissues, and its endogenous synthetic pathway has been discovered to be the same in plants such as the poppy m(Papaver somniferum). Endogenous morphine is supposed to have a certain role in homeostasis after trauma and severe illness as β-endorphin, an endogenous opioid peptide, does. Protein metabolism is one of the key components in the homeostasis. However, most studies about the effect of morphine on metabolism has been focused on the glucose metabolism. The purpose of this study is to investigate the mechanism of catabolic effect of morphine on the protein metabolism by analyzing protein metabolism and the levels of catabolic hormones after exogenous morphine administration. Morphine was infused intravenousely to one group of mongrel dogs, and intracerebroventricularly to another group. The glucose and leucine concentration and splanchnic balance were analyzed in each dog, and insulin, cortisol, and catecholamines were assayed. The following results were obtained. 1. About 15% of the infused morphine passed through the blood-brain-barrier from plasma to cerebrospinal fluid, but there was no appreciable movement from cerebrospinal fluid to plasma. 2. After intra cerebroventricular infusion of morphine, it was noticed that the increase of glucose concentration was more prominant than after intravenous infusion in the early phase. At the same time hepatic and splanchnic g1ucose balance was significantly increased in intracerebroventricular infusion group. 3. Intracerebroventricular infusion of morphine increased the concentration of plasma leucine with increasing the hepatic and splanchnic leucine balance. But intravenous infusion decreased the plasma leucine concentration without any significant chanties of hepatic and splanchnic leucine balance. 4. The increases of cortisol and catecholamines were more prominent after intracerebroventricular infusion than intravenous infusion. 5. While the plasma insulin concentration was increased after intravenous infusion of morphine, it was not increased after intracerebroventricular infusion despite of higher blood glucose concentration. These results suggest that morphine has catabolic effect on protein metabolism by suppressing the secretion of insulin as well as by increasing the stress hormones via activating the sympathetic nervous system and pituitary-adrenal axis. This effect is supposed to be mediated by contract opioid system, not peripheral.restrictio

Utility of the International Classification of Diseases Injury Severity Score: Detecting preventable deaths and comparing the performance of emergency medical centers

Objective: The purpose of this study was to assess the ability of the International Classification of Diseases-based Injury Severity Score (ICISS) to detect preventable deaths, and to compare the performance of trauma care facilities. Methods: For 2 years, from 1997 to 1998, 131 trauma deaths and 1,087 blunt trauma inpatients from 6 emergency medical centers (EMCs) in Korea were reviewed. Trauma deaths were reviewed and the preventability of those deaths was judged by two professional panels. For both trauma deaths and trauma inpatients, the survival probability of each trauma patient was assessed using the ICISS full model. The degree of agreement in the preventability of trauma death between survival probability on the basis of the ICISS and judgment rendered by professional panels was determined, and the correlation between the Wscore and the preventable death rate in each EMC was also assessed. Results: The overall agreement rate between ICISS survival probability and preventable deaths judged by professional panels was 66.4% (kappa statistic, 0.36), and the positive predictive value of the ICISS in detecting preventable trauma deaths was 54.1% and the negative predictive value was 84.8%. The Spearman correlation coefficient between the W-score and the preventable death rate by each EMC was -0.77 (p = 0.07). Conclusion: The degree of agreement in the preventability of trauma death derived from the ICISS with a professional judgment on preventability was similar to that derived from the Trauma and Injury Severity Score. The W-scores of EMCs correlated well with their preventable death rates, with marginal statistical significance. This study has demonstrated that the ICISS is useful in detecting preventable deaths and in comparing the performance of trauma care facilities